APPLICATION FOR NONASSISTANCE SUPPORT SERVICES
FOR OFFICE USE:
Issuing Office:
DATE REQUESTED:
DATE GIVEN OR SENT:
TO:
DATE RECEIVED
Please return pages 1 through 6 with your application fee to our nearest Child Support
Recovery Unit office. See page 10 for a list of all our offices.
Be sure you:
_____ Send in your $25.00 application fee
_____ Sign and date page 6
_____ Return the “Authorization for Automatic Deposit” if you have not
already done so.
If you don’t send the fee and sign the application, we may delay or deny services.
470-0188 (Rev 04/16)
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Child Support Recovery Unit
APPLICATION FOR NONASSISTANCE SUPPORT SERVICES
INSTRUCTIONS
In order to get help from the Child Support Recovery Unit (Unit), you must:
• Fill out and return this application
• Pay the required fee
The child support program helps:
• Establish paternity
• Establish child support and medical support (Medical support could include health insurance or a cash amount to
help pay for medical expenses.)
• Collect regular support payments
• Enforce medical support
The amount we collect depends upon the payor’s income and assets. We pick the enforcement actions for your case.
To serve you better, we need your help. Please:
1.
Send us copies of all papers that establish paternity or support.
2.
Send us a clerk of court record of all support payments made on the case.
3.
Immediately tell us in writing or by telephone:
a) If you change your name, address, or phone number.
b) If you hire a private attorney.
c) If you decide you no longer want our services.
d) If your support order is modified.
e) If you get new information about the other parent’s location or employment.
We use many sources to help us find payors and their employers. But you may find this out before we do. Please tell us
by writing or calling your local office, listed on page 10. If you need assistance finding the local office that serves you, call
the child support automated information line at 1-888-229-9223 (toll free nationwide).
Iowa law says support payments have to be sent to our Collection Services Center (CSC). We send the payor a form
explaining how to make payments.
Here is how we apply payments to your case:
• First, we pay any current support due for the month. Whether support is for the current month is based on when
the employer withheld it, or when CSC gets it, depending on the source. If there is money left over, we pay the
newest balance due first.
• Once we send the payee at least $500 in a year, and if the children have never gotten public assistance, Iowa law
requires the payee to pay an annual fee of $25. We take this $25 fee from the support payments.
• If the children get public assistance, the payee assigns the support to the state for that period. This means we
pay the support we collect to the state. The state keeps the lesser of the public assistance paid or the amount of
assigned support.
• After the payee goes off public assistance, we pay:
o Any current support to the payee.
o Any past-due amounts due the payee.
o Any past due amount due the state.
• We only pay future support when:
o There are no past due amounts.
o The payment is for more than current support and is not from income withholding.
o The payor asks us to if the payment is from income withholding.
• If there is money due the state, the payee may review collections kept by the state through the automated
information line or on our web site.
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NONASSISTANCE SUPPORT SERVICES APPLICATION
(Please print legibly and return this application with your payment)
PAYEE INFORMATION
Payee’s legal name: (Last, First, Middle)
Social security number:
Date of birth:
Payee’s mailing address:
Home/Cell phone number:
Employer:
Home address if different from mailing address:
Employer address:
Employer phone number:
Relationship to children:
Payee’s maiden name or aliases:
Date and place of marriage:
Race:
Sex:
Height:
Weight:
Eye Color:
Hair color:
Scars, marks, tattoos, etc.:
Relationship to the payor: Spouse_____ Divorced_____ Common law_____ Never married_______
Payee’s social media usernames or URL’s:
Payee’s email address:
Have you gotten support enforcement services from another state?
Yes_______ No______
Name of State(s):___________________
INFORMATION FOR ALL CHILDREN FROM THIS MARRIAGE OR RELATIONSHIP ONLY
Legal Name (Last,
Sex
Social Security
Birth Date Birth City
Child is
Paternity
First, Middle
(M/F) Number
and State
living with
Established
Yes__No__
Yes__No__
Yes__No__
Yes__No__
Yes__No__
Yes__No__
Yes__No__
Yes__No__
Yes__No__
If the payee is pregnant from this relationship, when is her due date?
Address of children not living with the payee:
SUPPORT OBLIGATION INFORMATION
Does an order for support already exist?
Yes___ No____ Pending_____
If legal action to obtain support is pending, list the name, phone number, and address of the payee’s attorney:
If an order exists, check the type of order and complete the following:
Type of
Amount and Frequency Place of Order
Order
County/State
Temporary
order for
Per
support
Dissolution of
Marriage
Per
Paternity
Order
Per
Modification
of support
Per
Uniform
support
Per
470-0188 (Rev 04/16)
Date Order
Entered
Court Case
Number
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PAYOR INFORMATION
Payor’s legal name: (Last, First, Middle)
Payor’s mailing address:
Home address if different from mailing address:
Payor’s cell phone number:
Payor’s social media usernames or URL’s:
Payor’s email address:
Date and place payee last lived with payor:
Is the payor employed? Yes____ No_____
Payor’s maiden name or aliases:
Social security number:
Date of birth:
Home phone number:
Race:
Height:
Weight:
Sex:
Hair Color:
Eye Color:
Scars, marks, tattoos, etc.:
Age:
Payor’s most recent employer:
Employer’s phone number:
Has the payor provided any support? Yes_______
No________
If yes, describe below:
Type of support
Amount
How often received
Money
Provided food & clothing
Pays payee’s monthly bills
Vehicle owned or driven by payor:
Make:
Color:
Year:
Model:
License number:
State:
Unions or fraternal organizations:
Credit accounts/bank accounts:
Reason for payor’s absence:
Divorce____ Never married___ In Jail___ In Prison___ Legal separation___ Out of the country____
If in the Military, list what branch:
PAYOR’S INCOME AND RESOURCES
If known, list the type and amount of income the payor has:
Type of income
Amount
Wages (includes self employed)
Unemployment benefits
Social security or disability
Veterans benefits
Other
Tell us about any property the payor owns:
How often received
PARENTS, RELATIVES, AND/OR FRIENDS OF PAYOR
Name
Relationship
Address
Phone
Tell us other ways to locate or contact the payor:
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MEDICAL SUPPORT INFORMATION
Is any health insurance available to you or your child? Yes_____
No_____
If yes, who is enrolled? Self____ Self and Child____ None_____
Is there a support order that requires that medical support be provided? (Medical support could include health
insurance or a cash amount.) Yes_______
No______
If yes, explain_____________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Is there any health insurance available to the child’s other parent? Yes____ No____ Unknown_____
If yes, who is enrolled? Other parent______ Other parent and child_______ Unknown______
PLEASE COMPLETE THE FOLLOWING HEALTH INSURANCE BENEFITS SECTION.
Persons Covered
HEALTH INSURANCE BENEFIT SECTION
Name and address of insurance company
Policy Number
The date the coverage began: _____________________________________________
Type of coverage (Please check all that apply):
Family Medical _____
HMO ______
Family Dental ______
PPO _______
Individual Medical _____
Vision ______
Individual Dental ______
Other _______
Name of the person who has the policy:________________________________________________________
The person who has the policy is (please check):
Payee____ Payor____ Other (specify) _____________
COOPERATION REQUIREMENTS
You must cooperate in the following ways:
A. Come to our office to give us information we need to establish or modify support or paternity.
B. Appear as a witness at judicial or other hearings or proceedings.
C. Complete and sign forms we need.
D. Do other things we need to help establish, modify or enforce support.
E. Pay fees such as process server and annual fees when required.
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CERTIFICATION STATEMENT
NOTE: PLEASE READ CAREFULLY BEFORE SIGNING
My statements and the information I gave in this application are true and correct to the best of my knowledge
and belief.
I agree to notify the Unit if I change my address, and give the Unit my new address.
I agree to cooperate with the Unit in the establishment, modification or enforcement of a support obligation. I
understand that if I do not cooperate, the Unit may stop services.
I understand that listing Social Security Numbers for my children and myself is voluntary according to 42 USC
402(c)(2)(C). The Unit requests these social security numbers according to 42 USC 654 and 666 and Iowa
Code Chapter 252B. As provided by federal statutes at 42 USC 654A(d) and Title IV-D of the Social Security
Act, the Unit uses these social security numbers to establish, modify and enforce child support or medical
support, or to establish paternity or for other child support program purposes. The numbers may be released
to the other parent and to others because of these actions and purposes. The federal Privacy Act, 5 USC
552a note (1) requires the Unit to notify you of the possible disclosure and use of social security numbers.
By signing this application, I agree that the Unit can take any necessary legal action to establish, modify and
enforce a child and/or medical support obligation.
I understand that I may ask the Unit to close my case by notifying the Unit of my wish to cancel services.
I understand that the Unit can close my case under 441 Iowa Administrative Code 95.14(252B). If I ask, I may
receive a copy of that information. I understand I have the right to ask for a hearing to appeal the closing of my
case. If I appeal, I must make a written request within 30 days of the action that I am appealing, to the
Department of Human Services-Appeals Section, 5th Floor, 1305 East Walnut, Des Moines, IA 50314-0114.
I understand that if the payee received public assistance (FIP), support collected from the payor’s federal
income tax refund applies to the money due the state before the payee receives any.
I understand that the payee is personally liable to return any support the payee received from the Unit in error.
This includes money that the Unit must return to the Internal Revenue Service or the Iowa Department of
Administrative Services.
I understand that when the Unit accepts this application for services, one of the people with whom I may
discuss my case is an attorney who is an employee of the Unit or the Attorney General’s office. None of the
services provided to me establish an attorney-client relationship with either the Unit or the attorney. The
attorney works for the state of Iowa and represents only the state. By turning in this application, I admit that I
understand and accept this condition.
I understand that the Unit keeps information about people who receive child support services, including their
address, confidential. However, information may come out as a part of court actions to establish or enforce
support. Sometimes the court may order the Unit to release confidential information.
Applicant’s Signature:
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Date:
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CHILD SUPPORT SERVICES AND FEES
Iowa Code Section 252B, allows us to charge an application fee and fees to pay for actions we take on your
behalf. In most cases, the Unit charges the cost of establishing or enforcing an order to the person who pays
support. The person who asks us for a modification pays those costs. Following is a list of some of our
services and the fees:
APPLICATION FEE
You must pay a fee of $25 when you return this application. Please pay by personal check or money order
made payable to the Collection Services Center. You must pay the application fee before we provide any
support services.
ANNUAL FEE
The payee must pay an annual fee of $25 each year your family receives at least $500 in support and your
family has not gotten public assistance in any state. We take the fee out of the support payments.
FEES FOR COURT ACTIONS
You may have to pay costs for genetic testing, sheriff’s service fees or process server’s fees. If the other
parent lives in another state, you may have to pay the fees charged by that state.
LOCATION SERVICES
We search state and federal agencies’ computer files to locate the payor. Fee: There is no charge for this
service.
PATERNITY ESTABLISHMENT
We may establish paternity by an administrative process, parents may complete and file a paternity affidavit, or
we may prepare and file a petition with the court. Fee: SEE FEES FOR COURT ACTIONS, above. If you
establish paternity by affidavit, there is no fee.
ESTABLISHMENT OF A SUPPORT ORDER
We prepare and file petitions or administrative orders with the court for child support and medical support.
Fee: See FEES FOR COURT ACTIONS, above.
MODIFICATION OF A SUPPORT ORDER
We review support orders to see if the court should change the amount of the child support order or add or
change medical support. If so, we file an adjusted order with the district court. You can ask for this service by
filling out a Request to Modify a Support Order and sending it to the local office. You can get this form from
any local office. If you need assistance finding the local office phone number, call the child support automated
information line at 1-888-229-9223 (toll free nationwide). You may also visit our web site at:
www.childsupport.ia.gov. Fee: You may have to pay sheriff’s or process server’s fees.
ADMINISTRATIVE LEVY
We may seize the bank assets of a parent who has a support delinquency of at least one month’s support.
The amount seized is limited to the amount of the past due support. Fee: There is no charge for this service.
LICENSE SANCTION
We may tell licensing agencies to revoke or deny issuing a license. The parent must owe at least three
months’ worth of past due support. Drivers’ licenses, vehicle registrations, and recreational, business and
professional licenses may be affected. Fee: There is no charge for this service.
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SUSPENSION, SATISFACTION, AND REINSTATEMENT OF SUPPORT
Parents may jointly ask us to help get a temporary suspension of support. The parents must be reconciled and
living in the same household with some or all the children, or one or more children must now live with the
payor. If the situation changes within six months, we can ask the court to reinstate the order. Fee: See FEES
FOR COURT ACTIONS, above.
INCOME WITHHOLDING
We may enter an order to withhold support payments from the payor’s income. Support may be withheld from
wages, other earnings, trust income, unemployment benefits, Social Security benefits, Veteran’s benefits, and
worker’s compensation. Fee: There is no charge for this service.
INTERCEPTION OF FEDERAL INCOME TAX REFUNDS
We may take the federal income tax refund of a parent who owes past due support. The amount we take
is first applied to past due support assigned to the state before any amount is paid to the payee. Fee:
There is no charge for this service.
INTERCEPTION OF STATE INCOME TAX REFUNDS
We may take the state income tax refund of a parent who owes overdue support. Fee: There is no
charge for this service.
INTERCEPTION OF FEDERAL PAYMENTS
We may take a payment the federal government owes a person with a past due child support debt. Fee:
There is no charge for this service.
PASSPORT SANCTIONS
We may report a payor to the US State Department when the payor owes more than $2,500 in overdue
support. This prevents the payor from getting or renewing a passport. Fee: There is no charge for this service.
REFERRAL TO CREDIT AGENCIES
We may report a payor to credit agencies if the payor owes at least $1,000 in past due support. Fee: There is
no charge for this service.
CONTEMPT OF COURT
When the payor doesn’t pay support, we may ask the court for an order requiring the payor to show why
he/she is not in contempt of court. Fee: See FEES FOR COURT ACTIONS.
INTERNAL REVENUE SERVICE COLLECTION SERVICES
We may send the name of the payor to the Internal Revenue Service so that the IRS may attach real and
personal property. The IRS sells the property through public auction to satisfy the support debt. This process
may only be used if all other enforcement methods are unsuccessful and the past due support is at least $750.
Fee: The IRS charges a fee of $122.50 to the person requesting this service.
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CHILD SUPPORT AUTOMATED INFORMATION LINE
You can get more information about our services, including payment information, by calling the child support
automated information line at 1-888-229-9223 (toll free nationwide). Calling this number can also assist you in
identifying the local office phone number for your case. You may also visit our web site at
www.childsupport.ia.gov
SERVICES NOT AVAILABLE
We cannot:
1. Represent either parent in dissolution of marriage.
2. Represent either parent if the other parent files for contempt of court.
3. Represent either parent in a disagreement about custody, property settlement, visitation, outstanding bills,
or anything else in a court order not related to the payment of support.
4. Collect delinquent alimony payments not related to the payment of support.
If you need services we don’t provide, you may hire a private attorney or apply for legal aid services where
available. Please tell us if you hire a private attorney to provide the same services we do. This is so we can
avoid conflicting legal actions on your case.
Policy Regarding Discrimination, Harassment,
Affirmative Action and Equal Employment Opportunity
The Iowa Department of Human Services (DHS) policy on non-discrimination, harassment, affirmative action,
and equal employment can be viewed on the DHS website at the bottom of the page at: dhs.iowa.gov.
470-0188 (Rev 04/16)
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LOCATIONS OF THE IOWA CHILD SUPPORT RECOVERY UNITS
ANKENY CHILD SUPPORT RECOVERY UNIT
1605 SE Delaware Ave Ste A
Ankeny IA 50021-4595
515-369-2800
BURLINGTON CHILD SUPPORT RECOVERY
UNIT
409 N 4th St
PO Box 638
Burlington IA 52601-0638
319-753-6322
CARROLL CHILD SUPPORT RECOVERY
UNIT
625 N West St
PO Box 937
Carroll IA 51401-0937
712-792-5691
CEDAR RAPIDS CHILD SUPPORT
RECOVERY UNIT
411 - 3rd St SE Ste 200
Cedar Rapids IA 52401-1837
319-398-3619
CLINTON CHILD SUPPORT RECOVERY
UNIT
121 6th Ave So
PO Box 1175
Clinton IA 52733-1175
563-243-8237
COUNCIL BLUFFS CHILD SUPPORT
RECOVERY UNIT
300 W Broadway Ste 32
Council Bluffs IA 51503-9030
712-242-2358
CRESTON CHILD SUPPORT RECOVERY
UNIT
1103 S Sumner St
Creston, IA 50801-3545
866-219-9120
DAVENPORT CHILD SUPPORT RECOVERY
UNIT
3911 W Locust
Davenport IA 52804-3021
563-388-0409
470-0188 (Rev 04/16)
DECORAH CHILD SUPPORT RECOVERY
UNIT
317 Washington St Ste 2
Decorah IA 52101-1832
563-382-2666
DES MOINES NORTH CHILD SUPPORT
RECOVERY UNIT
6200 Aurora Ave Ste 301 E
Urbandale IA 50322-2865
515-369-2750
DES MOINES SOUTH CHILD SUPPORT
RECOVERY UNIT
525 SW 5th Street, Ste H
Des Moines IA 50309-4501
515-369-2860
DUBUQUE CHILD SUPPORT RECOVERY
UNIT
960 Main St
PO Box 3068 (Mailing Address)
Dubuque IA 52004-3068
563-557-7113
FORT DODGE CHILD SUPPORT RECOVERY
UNIT
330 1st Ave N
Fort Dodge IA 50501-3718
515-955-5464
GRIMES CHILD SUPPORT RECOVERY UNIT
3560 SW Brookside Dr Ste E
Grimes IA 50111-5062
515-369-2850
INDIANOLA CHILD SUPPORT RECOVERY
UNIT
1807 West 2nd Avenue
Indianola IA 50125-2145
515-962-5400
MARSHALLTOWN CHILD SUPPORT
RECOVERY UNIT
204 1/2 W State St
Marshalltown IA 50158-5842
641-753-6408
MASON CITY CHILD SUPPORT RECOVERY
UNIT
Mohawk Square, Ste 13
22 N Georgia Ave
Mason City IA 50401-3435
641-424-1147
OTTUMWA CHILD SUPPORT RECOVERY
UNIT
127 E Main Ste 100
Ottumwa IA 52501-2951
641-682-8802
PLEASANT HILL CHILD SUPPORT
RECOVERY UNIT
1300 Metro East Drive
Suite 114
Pleasant Hill IA 50327-8906
515-261-5870
SIOUX CITY CHILD SUPPORT RECOVERY
UNIT
520 Nebraska St Ste 218
Sioux City IA 51101-1315
712-255-2749
SPENCER CHILD SUPPORT RECOVERY
UNIT
20 W 6th St Ste 200
Spencer IA 51301-3907
712-262-1412
WATERLOO CHILD SUPPORT RECOVERY
UNIT
501 Sycamore Ste 400
Waterloo IA 50703-4651
319-291-2646
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